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Tuesday, January 8, 2008

Circle of Life

I don't usually blog these situations, but this one was notable and I've a few things I'd like to say about it.Today I am working. 8-7. 17 minutes into our shift this morning, we got a code 3 for a stroke, so we go puttering out there (can one 'putter' anywhere with lights and sirens?) to meet with a very pale, very weak, very sweaty elderly gentleman with virtually NO medical history. Quite healthy, in fact. He has no pain, no difficulty breathing, he can answer my questions: he is simply very weak and 'feels sick.' I did my initial assessment and discovered a blood pressure of 58/00 (normal= 120/80...generally people lose consciousness between 80-90/whatever, so this guy's pressure made me sit up straight). Coupled with his skin colour, I suspected something cardiac so we got him onto our cot, called ALS, and attempted an IV start (oxygen on, of course). I poked his arm in 3 places and had no luck, but ALS did far better than I once they got there. This patient looked SICK, felt SICK, and was getting SICKER by the minute, but he was still talking to me, and following commands. The ALS cardiac monitor revealed some pretty sombre signs and they decided to intubate. I was monitoring his airway while they prepped, and all of a sudden one of my periodic consciousness checks turned up unresponsive. A quick check: cardiac arrest.One minute he's looking me in the eyes and saying, "Oh, I don't feel good," and the next he's dead. It's striking to be there for that exact moment. I felt awe that I was priveleged to witness that moment in someone's life...while we sweated bullets to try and stave it off with CPR, atropine, epinephrine, saline bolus, intubation, ventilation, 12 lead, electronic pacing, etc, etc. This was my first 'witnessed arrest,' by which we mean witnessed by us and CPR intervention immediately initiated (a person's best chance of survival when their heart stops beating is with a witnessed arrest). I've done CPR before, on people found down but not down long, and I've certainly done my fair share of 'definately dead, don't attempt resuscitations,' but it is more rare to have a witnessed arrest like we had this morning. FYI, I have never done a successful resuscitation. Never. Our successful resuscitation rate in BC hovers around 14-16% (Seattle has the best success rate in North America, at 19%), so you can see that, while we give it everything we've got when someone's heart stops, it is generally a futile effort with minimal success. Now, that success rate is 'survival to hospital discharge,' so there are more people whose hearts restart but who don't survive the night, or the week, or the following month...anyways, I digress. But I digress in an interesting and slightly surprising (to the public, who watch too much unrealistic TV) direction.Another interesting digression: higher CPR/defibrillation resuscitation success rates are possible in the following categories:Hypoxic arrest-hanging-overdose-airway obstruction including occlusion of airway by unconscious person's tongue-drowning-smoke inhalationWith children

We worked and worked to give this gentleman the best possible chance for survival, but nothing we did helped. When it is someone's time to die, not even the most brilliant medicine on earth or the most perfectly executed protocol or the best resuscitation team can save them. Death keeps medicine humble, because our most powerful efforts are powerless before it, much of the time.My muscles are sore from my cycles of doing chest compressions. CPR is VERY hard work. My glasses kept slipping down my nose from the sweat on my face. I was also given the privilege of being entrusted with airway management (suction, ventilation, ensuring the tube doesn't go too far down the patient's trachea) in between chest compression rotations, which is a result of the trust relationship I've started to build up with ALS. Trust is good. Trust on a team makes all the difference in a situation like this one. Today I gained new respect for the ALS attendant in charge of this arrest because of the way he treated everyone in the room. He can be a gruff man of few words, but he was made specifically for moments like these, because he treated everyone with respect, calm consideration, and genuine compassion--firefighters, us BLS paramedics, his partner, and the many family members who were in the room. He kept the medical team working efficiently, and he kept the family informed of every step he was taking, giving them 5-10 minute updates on how things were going (not well, in general), and ensuring that they were a part of the decision making process and most of all, ensuring that they felt informed and empathized with. This paramedic has a LOT of things to do and to think about, and I admire that he felt the family's emotional well being to be one of his top priorities during this tragic event in their lives. In the end, we attempted to resuscitate him for over half an hour, and then called a doctor to pronounce his death. All our charms were not enough. I wonder if, as some people report, he watched us work for awhile before he left, from a corner of the room. I wonder if he feels peaceful now. I'm positive he does. He left behind a widow of 68 years. When we stopped our efforts and she came over to kiss him goodbye, I started to cry.Who am I, to witness these moments? I feel clumsy and rough, just standing beside people in their softest, saddest moments. I always want to reassure them by crying out, "I care! I'm not just a callous medical system robot, I feel alongside you, and I grieve that you grieve," but of course it is not about me so I am silent. I also think that life is beautiful, even in its ending. How can this be so? I don't know, but I find it to be. It is like shards of glass, or a Picasso, or a burnt forest. Fragments of what it was, but full of beauty nonetheless. This man was sometimes kind, loving, mean, selfish, tired, cranky, heroic, gentle, humorous; all the good and bad and full things we all are every day, and he was unique, and beautiful. And he left. His life is gone.Who am I, to see this?

I always thought that calling someone a friend was better than calling someone a relative. You know? I can choose friends, can't choose relatives. It was my attempt at saying I like you more than just you being my cousins' wife. :-)